Rush Copley Healthplex Camper Profile

Camper Information

Camper Name

First

Middle

Last

Suffix

Date of Birth

Age

Gender

Camper Address

Street Address

Unit, Suite, etc.

City/Town

State/Province

ZIP/Postal Code

Is the camper a member of the Rush Copley Healthplex?

Yes

Does your child have siblings in the program?

Yes

If yes, please list name(s) and age(s):

Re-order	Sibling Name	Sibling Age	Weight	Operations
	Sibling Name	Sibling Age	Item weight

more items

Camper Swimming Ability

Non-swimmer

Fair swimmer

Good swimmer

Camper T-Shirt Size

(All campers must wear camp shirts on Field Trips)

I give permission for staff to assist my child in applying sunscreen, if necessary.

Yes